DH16 - Doctors’ health contextual unit

Rationale

Doctors’ health is the understanding and practice of safe health behaviours that are necessary to achieve and maintain physical, psychological and social wellbeing. It is widely recognised that well balanced and healthy doctors are able to provide higher quality patient care through enhanced empathy, skills in imparting positive health messages and through being less likely to make mistakes due to stress and fatigue. Medicine tends to attract personalities who are hardworking, self-sacrificing and who hold themselves to high standards with tendencies to self-criticism.1,2 Unfortunately, general practitioners are often more diligent in caring for their patients than they are for themselves.

General practitioners (GPs) can have their physical and psychological health impacted by their work in a number of ways. The process of providing high-quality continuity of care to a wide spectrum of patients with a broad range of complex conditions including physical, psychological and social issues can be challenging. Dealing with any combination of time pressures, insufficient resources, poor remuneration, lack of appreciation, aggressive patients who may threaten a doctor’s physical safety or patient complaints with the threat of medico-legal issues can be extremely stressful.

Doctors are at risk of being bullied, particularly when working in junior roles. Research suggests that 21% of Australian doctors have experienced bullying at work.3

GPs are at risk of experiencing psychological issues such as stress, anxiety, depression, burnout, addiction (particularly to alcohol and prescription drugs) and dysfunctional interpersonal relationships.4–6

Burnout may be recognised by a number of signs including persistent fatigue (with recognition that other pathologies need to be excluded if this occurs and cynicism, emotional exhaustion, feelings of depersonalisation (some describe this as a reduction in capacity to empathise with patients) and/or perceptions of being ineffective. It is concerning that at any point in time, it is estimated that one in three doctors is suffering from burnout. Recognising and addressing signs of burnout are thus imperative skills for all GPs.7–9

Many general practitioners do not have their own independent GP. There are often barriers to accessing quality continuity of care, such as professional stigma, and thus many individuals self-diagnose and self-medicate, ignore signs and struggle to admit illness – which for many is seen as a sign of failure.5,6 It is imperative that GPs have the insight to recognise if and when their acute or chronic, physical or mental health condition begins to impair their ability to provide care so that they access care for themselves in a timely manner. It should be noted that having a chronic illness rarely correlates with impairment to practice.

Doctors should see themselves as people who practise medicine – that is, people first and foremost – with all the human needs and weaknesses that apply to the rest of the population.10–12In addition to optimising their health for personal wellbeing, doctors also have a professional obligation to maintain their own health.

In order to achieve and maintain health, general practitioners need to be skilled in self-awareness and self-care. Doctors need to be able to access support and appropriate care when needed, and thus it is vital for every GP to have their own GP. This care includes that provided to the rest of the population, such as risk-appropriate screening and support for health-promoting behaviours such as stress management, having a healthy diet, exercise and participation in fun and enjoyable activities, and developing robust structures to address professional isolation and to achieve and maintain social and emotional wellbeing. Such structures to support health may include:

demanding a good work–life balance (and, importantly, not seeing this as being a sign of weakness)

having fun regularly.

Seeking out peers to be mentors who successfully model work–life balance and healthy behaviours is also to be strongly recommended.13

GPs who are recognised to be particularly at risk of having difficulty accessing care are rural doctors. Other groups of GPs at risk of developing health issues related to their work are new graduates who experience unique pressures and access issues,2,12and GPs who work with vulnerable communities or groups of patients such as Aboriginal and Torres Strait Islander communities, refugees and asylum seekers, palliative care patients, victims of family violence,
and patients with complex post-traumatic stress disorders, addictions or severe mental health and/or social problems. International medical graduates and female GPs are also at increased risk.14,15

Another very important aspect of doctors’ health is that general practitioners look out for and support each other both by recognising if a colleague may be impaired or at risk of being impaired and supporting them to access help.

Physician impairment is defined as any physical, mental or behavioural disorder that interferes with the ability to engage safely in providing good-quality care to patients. It is the responsibility of the profession to ensure both that staff are safe at work and that the public is protected from harm.10

Treating doctors – The doctor as a doctor’s doctor

Developing skills in being a GP to other doctors carries with it complexities, but is an extremely important role. Boundary issues are an important component of doctors’ health and delivering patient-centred care can be challenging.16 All GPs need the skills to ensure that they understand the boundaries related to decisions regarding self- treatment, seeking independent healthcare and caring for the doctor-patients.16,17 Doctors and their families may have poorer health outcomes as patients in the health system due to under- and over-treatment and inappropriate referrals.18 Treating doctors must be mindful that medical families may also be disadvantaged in their healthcare access.

Doctors, like many members of the public, may find making the transition to being a patient difficult. Like all patients, doctors have the right to privacy and confidentiality and should not have any of their details disclosed by the treating GP unless obliged ethically or legally to do so in regards to mandatory reporting. Fear related to mandatory reporting can be a barrier to accessing care. It is a professional responsibility for all GPs to understand the law and their responsibilities, recognising that there is a high threshold for reporting.12,19,20

Doctors may have unique issues relating to their own health, and treatment should be sensitive to these needs.21,22Doctors treating medical practitioners need to ensure that the same due care is offered when caring for doctors as for other patients. General practitioners should follow their usual method of history-taking, examination and investigation, as they would with any other patient, without taking shortcuts or making assumptions.23

Treating doctors should recognise that doctor-patients require the same explanations of investigations and management and be prepared to act as an advocate within the medical system as they would for all patients, including in regard to special issues relating to return to work after illness or impairment.

Doctor-patients often need to be reassured that they have made the right decision in seeking medical care, even if the problem appears to be a minor one. They need to be included in the routine recall system for follow-up and screening and encouraged to develop a continuing regular relationship with their practitioner.
Treating doctors should encourage doctor-patients to participate in a shared decision-making process with the guidance normally offered to any patient. Doctor-patients should be allowed to be the patient and not be expected to make decisions without support. This therapeutic alliance should, however, demonstrate respect for and acknowledge the doctor-patient’s clinical knowledge.10,16,24

When caring for an ill and potentially impaired doctor, treating doctors need to accept their professional and ethical responsibility to ensure that the doctor receives care and that the general community is protected.25

A career in general practice can be incredibly fulfilling and rewarding if robust strategies and structures are created and maintained to optimise the physical and emotional health of the doctor for the long term. Self-awareness, self-care and willingness to support and assist colleagues are key ingredients to achieving this.